inforMED
MalfunctionLWH

SURGICOUNT SPONGE COUNTER

Received Oct 7, 2024 · Event occurred Jul 16, 2024

Report 20384181 · MDR key 20384181

Device

Generic name

Counter, Sponge, Surgical

Model number

0696-002-002

Catalog number

0696-002-002

Patient

2 MO · Female

  • No Clinical Signs, Symptoms or Conditions
  • No Clinical Signs, Symptoms or Conditions

Narrative

Description of Event or Problem

I HAD AN ISSUE WITH THE SURGICOUNT SPONGE COUNTER. THE SCRUB TECHNICIAN AND I WERE READY TO COUNT, AND I HAD THE SURGICOUNT MACHINE ALL READY TO SCAN IN THE NEW SPONGES. I HAD ALREADY SCANNED MY BADGE AND THE PATIENT'S INFORMATION TO START A NEW CASE. THE "COUNT IN" SCREEN WAS ON AND SHOWED NOTHING WAS SCANNED IN YET SINCE IT WAS THE START OF A NEW CASE. WHEN THE TECH WENT TO SCAN OUR 15 LAP SPONGES IN, SUDDENLY THE DISPLAY CHANGED AND SAID THAT 30 SPONGES HAD INITIALLY BEEN COUNTED AND 15 HAD BEEN COUNTED OUT. IT HAD SWITCHED OVER TO THE "COUNT OUT" SCREEN ALSO WITHOUT ANYONE TOUCHING IN. THE TECH AND I WERE BOTH CONFUSED ON HOW IT HAD MESSED UP SINCE EVERYTHING LOOKED NORMAL UP UNTIL SHE SCANNED THE SPONGES. SINCE IT THOUGHT WE HAD 30 SPONGES AT THE START AND HAD ALREADY SCANNED OUT SPONGES WE HADN'T EVEN USED YET, I ABORTED THE CASE AND PUT A NOTE IN THE CASE LOG EXPLAINING THE ERROR.